Annals of International Medical and Dental Research - Volume 3, Issue 6, November - December 2017

ISSN (0):2395-2822; ISSN (P):2395-2814

A Comparative Study of Histopathology of Different Types
of Nasal Polyps: Allergic, Inflammatory and Neoplastic.

Pankaj Tripathi!, Rajesh Ranjan?
1Associate Professor, Department of Pathology, TSM Medical College, Anaura, Amausi, Lucknow.
2Assistant Professor, Dept of community medicine, Rama medical college.

Received: July 2017
Accepted: August 2017

Copyright: © the author(s), publisher. It is an open-access article distributed under the terms of the Creative
Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and
reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Nasal polyp is a multifactorial disease, with infectious, non-infectious, inflammatory, anatomic and genetic
abnormalities. Most theories consider polyps to be the ultimate manifestation of chronic inflammation. Methods: A total
number of 6250 biopsies from different departments were received at the Department of Pathology for a period of 2 years.
The specimens were processed and sections were stained with conventional Haematoxylin and Eosin stain and
systematically examined. Toluidine blue staining was carried on sections which were diagnosed as non-neoplastic on H&E.
Results: Majority of patients were in second (37.5%) and third (12.5%) decades of life. In case of nasal polyp, male
patients (30) predominated over female patients (18) with a M:F ratio of 1.7:1. Nasal obstruction was the most common
symptom. Most of nasal polyps were lined by pseudostratified ciliated columnar epithelium (79.1%) and had severe
oedematous stroma. Out of 18 neoplastic polypoidal lesions, 16 (88.8%) were benign and only 2 (11.2) were malignant
neoplasm. Conclusion: The use of clinical criteria as a method of selecting nasal polyps for histology proved inadequate
as several cases of polyps with sinister pathology would have escaped diagnosis. Routine histology is recommended, as
no definite diagnosis on the basis of history and clinical examination is adequate.

Keywords: Allergy, Histopathology, Nasal polyp, Neoplasm.

pedunculated. The true nasal polyps are the tumour
like non-neoplastic polypoid masses arising from
nasal cavity and sinuses. Two types are encountered
— one is associated with nasal allergy and numerous
eosinophilic infiltration of stroma and other is found
in relation to chronic naso-sinusoidal infection
termed the inflammatory or granulomatous polyp.”!

INTRODUCTION

Nasal polyps were first described more than 3000
years ago and comprise the most common group of
mass lesions encountered in the nose. Despite this
long history and frequent occurrence, a great many
questions still exist with regard to incidence,

pathogenesis and treatment.

Nasal polyp is a multifactorial disease, with
infectious, non-infectious, inflammatory, anatomic
and genetic abnormalities. Most theories consider
polyps to be the ultimate manifestation of chronic
inflammation."

Nasal polyps are essential rounded projections of
oedematous mucous membrane. They may develop
in association with chronic hypertrophic rhinitis,
chronic sinusitis and allergic diseases of the nose.
They are solitary or multiple, unilateral or bilateral.
They arise most commonly in the ethmoidal air cells
are filled by sessile polyp, where polyps that arise
from surface mucosa are likely to become

Name & Address of Corresponding Author
Dr. Rajesh Ranjan
Assistant Professor,

Dept of community medicine,
Rama medical college.

Clinically, it is quite impossible to distinguish
between simple nasal polyps, polypoidal lesions due
to specific diseases and polypoidal neoplasms
(benign and malignant). For this reason, it becomes
important that all polyps and polypoidal lesions of
nose should be submitted for histopathogical
examination. 34)

In a study, it was reported that meningiomas were
polypoid, rubbery in consistency, and in nasal cavity
may give the impression of simple polyps. In another
study of non-epithelial neoplasms, fibromas of the
upper respiratory tract have been described as
polypoidal lesions occurring in nasal cavity, pharynx
and larynx. It has been said that about one percent of
malignant melanoma develops in mucosa of head
and neck. The nasal cavity is the commonest site,
followed by mouth.©!

Rhabdomyosarcoma is divided into 4 types, which
has been generally accepted. Some researchers drew
attention to existence of embryonal type of
Rhabdomyosarcoma in the head and neck region
having a resemblance to the sarcoma botyroides in

Canals of Intemational Medicat and Dental Research, Vat (3), Josue (6)

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infantile genital tract. It is the most common
paediatricmesenchymal neoplasm, comprising 50 %
of all soft tissue sarcomas in this age group. More
than one third is located in head and neck region. In
a study of 170 cases of Rhabdomyosarcoma,
majority (77.7%) were seen in children less than 12
years of age.'

The presence of peripheral nerve tumors in the nose
and sinuses is present in literature. It was mentioned
that peripheral nerve tumors can occur in nose and
sinuses and usually of schwannoma type.

Angiectatic nasal polyps should prevent confusion of
such lesions with other vascular or spindle cell
lesions. A study at Armed forces institute of
pathology about oto-laryngeal tumors disclosed 88
cases of sino-nasal polyps with atypical stromal cells
over a 20 year period. It was emphasized that
cellular atypia in stromal cells of nasal polyps was
due to response in fibroblasts or fibro-histiocytes to
increased intercellular fluid and _ vascular
compromise."7]

It was reported that rhinosporidiosis is a chronic
granulomatous disease in endemic zones of India,
including West Bengal. In a study it was reported
that allergic fungal sinusitis was most common form
of fungal sinusitis. Acute fulminant (invasive) fungal
sinusitis is another subtype, caused by etiological
agents, belonging to, Mucoraeceae — which includes
Rhizopus, Mucor and Absidia. It was observed that
allergic fungal sinusitis occurs as a spectrum of
disease ranging from mild sinus disease and atopy
(with or without fungi) to severe expansible sinusitis
with extremely high total Immunoglobulin E
levels.©!

The earliest description of inverted papilloma was
published in 18th century. Ringertz was first to
describe the downward (invert) growth of epithelium
into stroma, thus giving this tumor its present name
of inverted papilloma. Barnes and Bedatti used the
term Schneiderian papilloma due to prominent
eosinophilic granularity of tumor cells. Pleomorphic
adenoma was first reported by Ahlborn in nasal
region. The epithet “Mixed” was first introduced by
Paget in 1853. It has been stated that pleomorphic
adenomas comprise less than 10 percent of all
glandular tumors in the nasal region.”!

MATERIALS AND METHODS

The present study was undertaken over a period of
two years. A total number of 6250 biopsies from
different departments were received at the
Department of Pathology, out of which 456 biopsies
were received from Otorhinolaryngology (ENT)
department constituting about 7.2% of all biopsies.
119 biopsies were from nasal cavity, paranasal
sinuses and nasopharynx forming 26.09% of ENT
biopsies and 1.9% of the biopsies received from
other departments.

Attention was paid to record the clinical history and
examination findings of each patient in the

Canals of Inteunational Medical and Dental Research, Vat (3), Josue (6)

proforma. The specimens were processed and
sections were stained with conventional
Haematoxylin and Eosin stain and systematically
examined. Toluidine blue staining was carried on
sections which were diagnosed as non-neoplastic on
H&E. Mast cells in these polyps was counted in the
epithelium and stroma.
Various parameters which were recorded are:
a) Age and sex of patient.
b) Clinical presentation of patient.
c) Laterality of the lesion.
d) Nature and type of surface epithelium in
nasal polyps.
e) Stroma of nasal polyps.
f) Inflammatory cell population in stroma of
simple nasal polyps.
g) Types of neoplastic polypoidal lesions.

RESULTS

Simple nasal polyp's occurred over a wide age range.
The youngest patient was 10 years old and oldest
patient was 56 years old. Majority of patients were in
second (37.5%) and third (12.5%) decades of life
[Figure 1].

Number of cases

0-10
10 pit) 30 40 50 60

Figure 1: Age incidence of simple nasal polyps.

Table 1: Sex incidence of simple nasal polyps.

Age Male Female Total Ratio
0-10 1 1 2 La
11-20 12 6 18 2:1
21-30 6 5 11 1.2:1
31-40 4 2 6 2:1
41-50 3 2 5 1.5:1
51-60 4 2 6 2:1
Total 30 18 48 17:1

In case of nasal polyp, male patients (30)
predominated over female patients (18) with a male:
female ratio of 1.7:1 [Table 1].

Table 2: Clinical features of polyps and polypoidal

lesions.
Clinical Features No. of Cases
Nasal Obstruction 55
Nasal Mass 18
Allergic Symptoms (Sneezing, Rhinorrhea) 15
Nasal Discharge
a) Serous 15
b) | Mucopurulent 30
Epistaxis 25

In majority of cases, (55 cases) nasal obstruction was
the most common symptom. Nasal discharge was

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frequently noted in majority of patients (45 cases), of
which 30 patients had mucopurulent discharge,
while 15 patients had watery discharge. Epistaxis
was also noted in 25 patients. Allergic symptoms
like sneezing and rhinorrhea were noted in 15 cases.
Nasal mass lesions were observed in 18 cases.
Majority of polyps and polypoidal lesions presented
with multiple symptoms [Table 2].

No. of Cases

y

Unilateral

® Bilateral

Figure 2: Laterality of nasal polyps and polypoidal
lesions.

Table 3: Nature and type of surface epithelium in nasal

lymphocytes, plasma cells, eosinophils, neotrophils
and macrophages. Most polyps had a dense infiltrate
of eosinophils, lymphocytes and plasma cells.
Neutrophils and macrophages were scanty in most
polyps. Average number of cells 7.5 hpf was taken
to approximately quantitate the inflammatory cell
population as dense (>50) moderate (30-50) and
scanty (<50) [Table 5].

Table 6: Types of neoplastic polypoidal lesions.

A. Benign No. of | Percentage
Cases
a. Epitheloid 1 aye)
haemangiondothelio
ma
b. Capillary 5 27.8
haemangioma
c. Angiofibroma 1 5.5,
d. Inverted papilloma 8 44.5
e. Nasal glioma 1 eye)
Total 16 88.8
B. Malignant
a. Olfactory 1 5.6
neuroblastoma
b. Undifferentiated 1 5.6
nasopharygeal
carcinoma
Total 2 11.2

polyps.
Surface Epithelium No. Percentage
of
Cases
A. 05 10.5
IL Non ulcerated
IL Ulcerated 43 89.5
Total 48 100.0
B. 38 79.1
IL Pseudostratified ciliated
colummar epithelium
IL Squamous epithelium 9 18.8
Il. Transitional epithelium 1 2.1
Total 48 100.0

Most of nasal polyps were lined by pseudostratified
ciliated columnar epithelium (79.1%) and had severe
oedematous stroma. [Table 3,4].

Table 4: Stroma of nasal polyps.

Stroma Severe | Moderate | Minimal | Nil
(%) (%) (%) (%)

Oedematous | 22 14 (29.2) 9 (18.7) 3 (6.3)
(45.8)

Vascular 8 (16.7) | 16 (33.3) 24 (50.0) | -

Fibrosis 5 (10.3) 2 (4.2) 3 (6.3) 38

(79.2)

Table 5: Inflammatory cell population in stroma of
simple nasal polyps.

Cells Dense Moderate Scanty
(%) (%) (%)
Lymphocytes 32 (66.7) 6 (12.5) 10 (20.8)
Plasma Cells 16 (33.3) 24 (50.0) 8 (16.7)
Mast Cells 7 (14.6) 5 (10.4) 36 (75.0)
Macrophages 1 (2.1) 4 (8.3) 43 (89.6)
Polymorphs 2 (4.2) 4 (8.3) 42 (87.5)
Eosinophils 12 (25.0) 22 (45.8) 14 (29.2)

The type and density of inflammatory cell
population was observed. Majority of the polyps had

Out of 18 neoplastic polypoidal lesions, 16 (88.8%)
were benign and only 2 (11.2) were malignant
neoplasm. In 16 (88.8%) benign lesions presenting
as polypoidal lesions, Inverted papilloma (8cases)
and Capillary haemangioma (5 Cases) were the most
frequent benign tumours followed by Epitheloid
haemangioendothelioma (1 case), Angiofibroma (1
case), Nasal glioma (lcase). Out of the 2 (11.2)
malignant lesions presenting as polypoidal masses a
solitary case of undifferentiated nasopharyngeal
carcinoma and a_ solitary case of olfactory
neuroblastoma was detected [Table 6].

DISCUSSION

Polyps and polypoidal mass in nose and_ nasal
sinuses are very common lesions encountered in
clinical practice. It may be due to most frequently
occurring simple nasal polyps or polypoidal lesions
due to a variety of other pathologic entities ranging
from infective granulomatous disease to polypoidal
neoplasm including malignant ones. "©!

The nose and nasal sinuses are exposed to a variety
of infections, chemically agitating, antigenically
stimulating, mechanical, and traumatic and many
other influences.

Although majority of nasal polyps sent for histology
are inflammatory secondary to infection, allergy or
idiopathic causes; a variety of clinical conditions,
also present as nasal polyps ranging from benign
lesions to malignant nasal tumors. Therefore an
assessment of a clinician's ability to distinguish
between ‘common’ nasal polyps and those of sinister
aetiology is needed to determine the benefit of

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ending nasal polyps for
examination. !!!!

In the present study, male to female ratio was 1.7:1,
with a male predominance. Ratio of male in the
study group of Vento et al,!!”! is 2.4:1 (82 males and
33 females) and Diamantopoulos I et al,"'7! showed
male to female ratio of 3.3:1 (57 males and 17
females). According to Kirtsreesakul. V there is a
strong male predominance with a ratio between 2:1
and 4:1. In most of the studies discussed so far, male
predominance was noted.

Histological analysis of epithelium of nasal polyps
in the present study showed ulceration in 89.7% of
polyps. Majority of the polyps are lined by
Pseudostratified ciliated columnar epithelium in 25
cases (86.2%). As in present study, ulceration of
epithelium found in majority of cases may is due to
trauma or due to pressure of enlarging polyps against
rigid structures causing devitalization.

In a study by Stamm AC et al,"!62% of nasal polyps
(65 cases) were lined by pseudostratified ciliated
columnar epithelium with goblet cells and ciliary
cells. In anterior nasal polyps, some have reported
the finding of stratified squamous non-keratinized
epithelium or transitional epithelium also.

In a study by Ruhno J et al 46% of polyps were lined
by ciliated columnar epithelium and almost 113
cases (100%) showed ulceration of surface
epithelium in nasal polyps.”! In a study conducted
by Triglia JM et al,! microscopically, the polyps
had a ciliated respiratory epithelium but often
surface ulceration was seen. Many studies on the
histology of nasal polyps have described that they
have a respiratory epithelium with pseudostratified
ciliated columnar cells and goblet cells. According to
Stamm AC et al!" the surface epithelium is
composed of intact respiratory epithelium, but may
also show squamous metaplasia.

In the present study, significant feature was the
constant presence of inflammatory cells in the
stroma of nasal polyps. Most polyps in present study
showed varying degree of cellular infiltrate
consisting of eosinophils, lymphocytes stroma cells
and mast cells. Macrophages and neutrophils were
scanty in majority of cases.

Various attempts to subgroup nasal polyps on a
histological basis were totally unsuccessful.
Histopathologists often face difficulty in
subgrouping the nasal polyps as allergic and non-
allergic, or as inflammatory polyp and allergic
polyp."

Mygind classified polyps into two groups, those
containing large number of ecsinophils and those
containing large number of neutrophils. In the
present study, we could not classify polyps into
eosinophil or neutrophil polyps as by Mygind
because in majority of the polyps eosinophils were
present.it is tempting to classify to ecsinophils
polyps as allergic because they were often associated

histo-pathological

with asthma and perennial climates, but relationship
between polyps and allergy is not clear.

Lathi et al stated that allergy was a causal factor in
the development of nasal polyps, however many
other authors have considered the relationship to be
co-incidental."!

Patients with polyps have about the same prevalence
of positive skin tests as does the normal population.
Additional evidence against the hypothesis of allergy
as a causal factor is that polyps seldom occur in
children or young adults with atopic hay fever and
allergic asthma. Nasal polyps arising is non-allergic
group also showed significant number of
eosinophils.

In a study conducted by Stamm et al,"! 10.6% were
allergic polyps and 31.9% non-allergic or
inflammatory polyps, the rest being mixed type.

In the study by Zafar U et al,'°! lymphocytes plasma
cells and macrophages were present in moderate
number in 61.1%, 70.8% and 67.3% instances
respectively. Eosinophils were present in 48.7% of
cases and rest of polyps showed presence of
moderate to poor eosinophils. In majority of cases
plenty to moderate number of mast presence in
58.4% cases.

CONCLUSION

The clinical information on the requisition form and
diagnosis made by the clinician was compared with
final histopathological diagnosis. The use of clinical
criteria as a method of selecting nasal polyps for
histology proved inadequate as several cases of
polyps with sinister pathology would have escaped
diagnosis. Routine histology is recommended, as no
definite diagnosis on the basis of history and clinical
examination is adequate.

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U. Zafar, N. Khan, N. Afroz, S. A. Hasan. Clinicopathological
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How to cite this article: Tripathi P, Ranjan R. A
comparative study of histopathology of different types of
nasal polyps: Allergic, Inflammatory and Neoplastic. Ann.
Int. Med. Den. Res. 2017; 3(6):PT41-PT45.

Source of Support: Nil, Conflict of Interest: None declared

Annals of Intemational Medical and Dental Research, Val (3), Josue (6)

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